Evergreen Retirement Home
Profile & contact details
|Premises name||Evergreen Retirement Home|
|Address||120 Rathgar Road Henderson Auckland 0610|
|Service types||Rest home care|
|Certification/licence name||Henderson Retirement Home Limited - Evergreen Retirement Home|
|Current auditor||HealthShare Limited|
|End date of current certificate/licence||06 December 2020|
|Certification period||36 months|
|Provider name||Henderson Retirement Home Limited|
|Street address||121B The Drive Epsom Auckland 1023|
|Post address||121B The Drive Epsom Auckland 1023|
Progress on issues from the last audit
What’s on this page?
This rest home has been audited against the Health and Disability Services Standards. During the last audit, the auditors identified some areas for improvement.
Issues from their last audit are listed in the corrective actions table below, along with the action required to fix the issue, its risk level, and whether or not the issue has been reported as fixed.
A guide to the table is available below.
Details of corrective actions
Date of last audit: 04 October 2017
|Outcome required||Found at audit||Action required||Risk rating||Action status||Date action reported complete|
|Advance directives that are made available to service providers are acted on where valid.||There is a lack of clarity around advance directive for residents deemed not competent to make a decision.The doctor signs for or not for resuscitation and the family also signs to state that they are engaged in the discussion.||Ensure that any advance directive is made by a resident who is competent to do so or by a doctor if a clinical decision is appropriate with this documented clearly on the advance directive form.||PA Low||In Progress|
|Information of a private or personal nature is maintained in a secure manner that is not publicly accessible or observable.||Resident records are not held in a confidential manner.||Keep resident records stored in a confidential manner.||PA Low||In Progress|
|During a temporary absence a suitably qualified and/or experienced person performs the manager's role.||Documentation to confirm a suitably qualified and/or experienced person to perform the manager or registered nurse position in the event of a temporary absence is not complete.||Ensure that there is documentation to confirm who is suitably qualified and/or experienced to perform the manager role and who will relieve for the registered nurse during a temporary absence.||PA Low||In Progress|
|Entry criteria, assessment, and entry screening processes are documented and clearly communicated to consumers, their family/whānau of choice where appropriate, local communities, and referral agencies.||No record of consumers entering service and those referred to other services or referral agencies.||Ensure there is a record of consumers entering the service and those referred back to referral agencies.||PA Low||In Progress|
|Quality improvement data are collected, analysed, and evaluated and the results communicated to service providers and, where appropriate, consumers.||Meeting minutes include details of individual resident needs and issues and some reference to employee performance with this personal information communicated to staff.||Ensure that meeting minutes only include reference to the quality improvement programme and do not document individual resident or employee issues.||PA Moderate||In Progress|
|There are written policies and procedures for the prevention and control of infection which comply with relevant legislation and current accepted good practice.||Inconsistence use of hand gel sanitizer in between residents, wearing gloves during medication administration and disposing rubbish on top of the drug trolley.||Ensure infection control practice reflect accepted good practice as per policies and procedures.||PA Low||In Progress|
The outcome required by the Health and Disability Services Standards.
Found at audit
The issue that was found when the rest home was audited.
The action necessary to fix the issue, as decided by the auditor.
Whether the required outcome was partially attained (PA) or unattained (UA), and what the risk level of the issue is.
The outcome is partially attained when:
- there is evidence that the rest home has the appropriate process in place, but not the required documentation
- when the rest home has the required documentation, but is unable to show that the process is being implemented.
The outcome is unattained when the rest home cannot show that they have the needed processes, systems or structures in place.
The risk level is determined by two things: how likely the issue is to happen and how serious the consequences of it happening would be.
The risk levels are:
- negligible – this issue requires no additional action or planning.
- low – this issue requires a negotiated plan in order to fix the issue within a specified and agreed time frame, such as one year.
- moderate – this issue requires a negotiated plan in order to fix the issue within a specific and agreed time frame, such as six months.
- high – this issue requires a negotiated plan in order to fix the issue within one month or as agreed between the service and auditor.
- critical – This issue requires immediate corrective action in order to fix the identified issue including documentation and sign off by the auditor within 24 hours to ensure consumer safety.
The risk level may be downgraded once the rest home reports the issue is fixed.
Whether the necessary action is still in progress or if it is complete, as reported by the rest home to the relevant district health board.
Date action reported complete
The date that the district health board was told the issue was fixed.
Before you begin
Before you download the audit reports, please read our guide to rest home certification and audits which gives an overview of the auditing process and explains what the audit reports mean.
What’s on this page?
Audit reports for this rest home’s latest audits can be downloaded below.
Full audit reports are provided for audits processed and approved after 29 August 2013. Note that the format for the full audit reports was streamlined from 16 December 2014. Full audit reports between 29 August 2013 and 16 December 2014 are therefore in a different format.
Prior to 29 August 2013, only audit summaries are available.
Both the recent full audit reports and previous audit summaries include:
- an overview of the rest home’s performance, and
- coloured indicators showing how well the rest home performed against the different aspects of the Health and Disability Services Standards.
Note: From November 2013, as rest homes are audited, any issues from their latest audit (the corrective actions required by the auditor) will appear on the rest home’s page. As the rest home completes the required actions, the status on the web site will update.
Audit reportsAudit date: 04 October 2017
Audit type:Certification Audit
- Evergreen Retirement Home - Oct 2017 (docx, 43.75 KB)
- Evergreen Retirement Home - Oct 2017 (pdf, 170.07 KB)
Audit type:Surveillance Audit
- Evergreen Retirement Home - May 2017 (docx, 34.59 KB)
- Evergreen Retirement Home - May 2017 (pdf, 136.05 KB)
Audit type:Provisional Audit